Bo Ra Seo

DW Newell

HJ Buncke Jr

HJ Streefkerk

Jae Hyoo Kim

Joon Tae Kim

Jung Kil Lee

K Ooka

K Sugita

KG Krishnan

Ki Hyun Cho

KM Akay

M Kohno

Man Seok Park

N Tanahashi

R Sakalas

Soo Han Kim

Sung Pil Joo

T Ishikawa

Tae Sun Kim

English

PubMed

Springer - Publisher Connector

TECHNIQUE EVALUATION
The clinical utility of the Kopitnik arteriovenous
malformation microclip during STA-MCA bypass surgery
Sung Pil Joo & Tae Sun Kim & Bo Ra Seo & Jung Kil Lee &
Jae Hyoo Kim & Soo Han Kim & Joon Tae Kim &
Man Seok Park & Ki Hyun Cho
Received: 11 December 2008 /Accepted: 29 April 2009 /Published online: 26 May 2009
# The Author(s) 2009. This article is published with open access at Springerlink.com
Abstract
Purpose Yasagil temporary clips have been widely used in
extracranial-intracranial (EC-IC) arterial bypass surgery.
However, the extremely delicate vessels involved often
require the application of finer clips. We report on the use
of the Kopitnik arteriovenous malformation (AVM) micro-
clip system for superficial temporal artery-middle cerebral
artery (STA-MCA) bypass.
Methods Kopitnik AVM microclips are new mechanical
devices that are used during AVM surgery. They exert a pre-
defined closing force of 50–70 g, and also feature a special,
pyramid-shaped structure stamped on inner surfaces of the
blades. These characteristics avoid vascular intimal injury
and provide a secure grip. We prospectively studied their use
in 15 patients requiring STA-MCA anastomosis.
Results Clinical results were excellent and there were no
new ischemic events during 6-months’ follow-up.
Conclusions Kopitnik AVM microclips have several advan-
tages; they have small and variously sized clip blades (2, 3,
4 and 5 mm), and the small clip head allows the operator an
excellent view of the pathology and clip status. The
Kopitnik AVM microclip appears to be clinically effective
and safe for EC-IC bypass surgery, especially when smaller
vessels are involved.
Keywords Microvascular anastomosis . Microclip .
STA-MCA bypass
Introduction
A large variety of extracranial-intracranial (EC-IC)
bypasses are available, such as the standard superficial
temporal artery-middle cerebral artery (STA-MCA) by-
pass, radial artery intermediate-flow bypass, and saphe-
nous vein high flow bypass. The choice depends on the
pathological condition and the haemodynamic demands of
flow through the bypass. Of these techniques, STA-MCA
bypass is effective at improving cerebral perfusion in
selected patients with refractory cerebral ischaemia or
ischaemic moyamoya disease [3]. The Kopitnik arteriove-
nous malformation (AVM) microclip (Aesculap, Tuttlin-
gen, Germany) is a newly developed self-closing clip
device that has been used in AVM surgery (Fig. 1). The
present study was designed to evaluate the clinical
usefulness and safety of the Kopitnik AVM microclip for
STA-MCA anastomosis and to examine the qualities of the
anastomoses created.
Patients and methods
Patient population
Between March and September 2006, 15 patients (12 male
and three female patients) were enrolled in this study at
Chonnam National University Hospital and Medical
School. They had a mean age of 45.2 years, range 13–
67 years. The characteristics of patients and surgical
techniques that were used are summarized in Table 1. The
Acta Neurochir (2010) 152:547–551
DOI 10.1007/s00701-009-0399-x
S. P. Joo : T. S. Kim (*) : B. R. Seo : J. K. Lee : J. H. Kim :
S. H. Kim
Department of Neurosurgery,
Chonnam National University Hospital and Medical School,
8 HakDong, Dong-Gu,
Gwangju 501-757, Republic of Korea
e-mail: taesun1963@yahoo.co.kr
J. T. Kim :M. S. Park :K. H. Cho
Department of Neurology,
Chonnam National University Hospital and Medical School,
Gwangju, Korea
indications for STA-MCA bypass surgery were haemody-
namic compromise due to atherosclerotic stenoocclusive
cerebrovascular disease in 11 patients, and moyamoya
disease in four patients. Bilateral operations were per-
formed in one patient with moyamoya disease. Direct
revascularization through a standard STA-MCA bypass (11
operations) was performed in atherosclerotic stenoocclusive
cerebrovascular disease patients. In addition, in patients
with moyamoya disease, standard STA-MCA bypass (five
operations) was supplemented by indirect revascularization
via encephalomyosynangiosis (EMS).
Surgical technique
All patients were operated upon by the same surgeon. In
general, when the diameter of the MCA is less than
0.5 mm, direct anastomosis is not recommended. After the
donor artery has been approximated to the MCA cortical
branch, this branch is occluded proximally using a micro-
clip and an additional microclip distally. An arteriotomy
appropriate for the donor vessel diameter is made in the
recipient vessel using a microscissors (Fig. 4a), and the
Table 1 Summary of patient characteristics (Rt right, Lt left, ICA internal carotid artery, CTA computed tomographic angiography)
No Age Sex Symptom Diagnosis Operation
name
Occlusion
time (min)
Intraop.
sonographic
patency
Postop. CTA
patency(7days)
Peioperative
complication
1 31 F Rt. Arm
monoparesis
Lt ICA
stenosis
EIAB 40 Good Good
2 52 M Lt.
hemiparesis
Rt MCA total
occlusion
EIAB 32 Good Good Subdural
hygroma
3 46 M Rt.
hemiparesis
Lt ICA total
occlusion
EIAB 31 Good Good
4 38 M Lt.
hemiparesis
Rt ICA total
occlusion
EIAB 40 Good Good
5 46 M Lt.
hemiparesis
Rt ICA total
occlusion
EIAB 38 Good Good Chornic subdural
hemorrahge
6 31 F Rt.
hemiparesis
Moyamoya
disease
EIAB + EMS 36 Good Good
7 47 M Dizziness Rt MCA total
occlusion
EIAB 32 Good Good
8 51 M Rt.
hemiparesis
Lt MCA
stenosis
EIAB 36 Good Good
9 67 M Rt.
hemiparesis
Moyamoya
disease
EIAB + EMS 38 Good Good
10 13 F Rt.
hemiparesis
Moyamoya
disease
EIAB + EMS
(bilateral)
40 Good Good
11 56 M Rt.
hemiparesis
Lt ICA
occlusion
EIAB 32 Good Good
12 61 M Lt.
hemiparesis
Rt. ICA
occlusion
EIAB 38 Good Good
13 63 M Rt.
hemiparesis
Both ICA
stenosis
EIAB 36 Good Good
14 45 M Seizure Moyamoya
disease
EIAB + EMS 30 Good Good
15 63 M Rt.
hemiparesis
Both ICA
stenosis
EIAB 37 Good Good
Fig. 1 Photograph of the types of clip usually used during
extracranial intracranial arterial bypass. a Kopitnik AVM microclip,
b Yasargil temporary miniclip, c Yasargil temporary clip. Kopitnik
AVM microclips have a small head and are available in several clip-
blade sizes
548 S.P. Joo et al.
anastomosis completed using interrupted sutures. The
recipient vessel clip was removed initially, followed by
the donor vessel clip. The duration of cross-clamping of the
MCA branch was approximately 30–40 min, and the
anastomoses were assessed by microscopic observation
and sonographic micro-Doppler.
Water-tight closure of the dura is originally impossible
because the STA must run through the dural defect, which
is covered by temporal muscle. To reduce frequency of
subdural hygroma and subcutaneous cerebrospinal fluid
(CSF) collection, we made only a minimal opening of the
arachnoid membrane, and this was followed by suturing the
arachnoid membrane after STA-MCA bypass using a 10-0
nylon suture (Ethicon, Somerville, N.J.) to prevent CSF
leakage (Fig. 4b) in last four patients.
Follow–up
Oral aspirin (100 mg daily) was started for all patients on
the second postoperatively day. Postoperative computed
tomographic angiography (CTA) was performed at 7 days
postoperatively to assess the STA-MCA anastomosis in
each case. An experienced neuroradiologist and neurosur-
geon independently assessed the patencies of the bypass.
Results
Sixteen conventional STA-MCA anastomoses, including five
indirect revascularizations were performed in the 15 patients.
A summary of patient profiles is provided in Table 1. One
patient with moyamoya disease underwent a bilateral
operation. A standard interrupted technique using 10-0 nylon
sutures was used and 12 stitches were used for the bypass.
The average time required for anastomosis was 30 min when
12 sutures were required (two stay sutures and ten
interrupted sutures). Satisfactory anastomosis was achieved,
even in patients with small or friable recipient vessels,
recipient artery flow appeared to be increased in each patient
after anastomosis. Transient ischaemic attacks (TIAs) ceased
after operation and showed excellent bypass patency in each
patient. A complication occurred in two patients; a subdural
hygroma without mass effect and a chronic subdural
hematoma which were appropriately treated using burr hole
and drainage therapy. The Kopitnik microclip system had
shortcomings: (1) closure force was reduced suddenly when
clips were opened wide or applied several times; thus, they
are not reusable; (2) the clips are expensive; (3) they can not
be used in high-flow bypass surgery.
Fig. 2 Intraoperative findings
showing a small (approximately
5 mm), thin, friable recipient
artery. In this circumstance, finer
clips are needed, so as to avoid
recipient vessel injury
Fig. 3 Intraoperative photographs. a Arteriotomy appropriate for
donor vessel diameter being performed, with a short cross-clamp
distance so as not to injure the small perforating branch of the cortical
artery. b Arachnoid suturing preventing delayed leakage of CSF
The clinical utility of the Kopitnik arteriovenous malformation microclip during STA-MCA bypass surgery 549
Discussion
The development of microsuture materials and surgical
optical magnification has introduced new surgical possibil-
ities [2] to treat ischaemic brain diseases [9, 15]. Although a
range of surgical techniques can be used for STA-MCA
bypass, e.g. microsuture-tying forceps with attached scis-
sors [4], double insurance bypass [6], partial lateral clipping
[1], minimally occlusive microvascular anastomosis [5],
excimer laser-assisted non-occlusive anastomosis(ELANA)
[11, 12], and the microanastomotic system [7], each has
unique advantages and shortcomings.
Krishnan et al. [5] described a new technique for
performing microvascular anastomoses with persistent
perfusion using a temporary intraluminal microshunt. The
anastomosis can be performed via a minimally occlusive
technique that guarantees continuous blood flow and
prevents cerebral ischemia even if the suturing of the
anastomosis itself takes some time. Insertion of the micro-
catheter into the artery lumen may cause endothelial
injury and thromboembolism. The ELANA technique—
developed, clinically applied, and refined by Streefkerk et
al. [10–13]—may find wide application because of its
uncomplicated approach to solving the problem of brain
ischemia induced by temporary clipping during vascular
anastomosis. However, this technique is only suitable for
large calibre vessels (>3 mm) and carries doubt about the
precise patten of intima-to-intima alignment of vessels.
Yasagil temporary clips have been widely used in EC-
IC bypass surgery. Their closing force lies in the range
70–90 g. In animal experiments, at least 80 g was found
to be required to close an artery, and more than 120 g
damaged the arterial wall [14]. Ooka et al. [8] reported that
both the Sugita and Yasargil temporary clips show a
marked increase in closing force toward their bases (144
and 162 g, respectively), strong enough to damage an
arterial wall.
In our experience, direct anastomosis is difficult in
children with moyamoya diseases because the STA and
MCA are very small and thin, and their walls are extremely
fragile and vulnerable. Such extremely delicate vessels, so
as not to injure recipient vessels, often require the
application of finer clips than conventional Yasargil
temporary clips. We used a special AVM microclip system
for STA-MCA bypass (Fig. 2). The clips exert a pre-defined
closing force of 50–70 g and feature a special, pyramid-
shaped structure stamped on the inner surface of the blades
(Fig. 3). This allows tissue to sink between these pyramid
shapes, doubling the tissue contact surface, and ensuring a
secure grip of the vessel. These characteristics avoid injury
of vascular intima and reduce the possibility of delayed
thromboembolism. AVM microclips have a small clip blade
and head, and their characteristics allow minimization of
arachnoid dissection to about a 5-mm cross-clamp distance
and thus reduce injury of minute arterial branches from the
MCA (Fig. 4). In addition, the small clip head allows the
operator an excellent view of the pathology and clip status.
In the present study, all clips worked as intended in all
patients, and no failure to release or inadequate closure was
encountered.
Conclusion
It was feasible to use Kopitnik self-closing microclips for
STA-MCA anastomosis, especially with small-vessel dis-
ease; they did not adversely affect graft patency or quality
and after 6 months of follow-up appeared effective and
Fig. 4 Photograph of the Kopit-
nik clip and the inner surface of
its blade. a Yasargil temporary
clip, b Kopitnik AVM microclip.
The Kopitnik AVM microclip
features a smoother groove on
its inner blade surface than the
Yasargil temporary clip
550 S.P. Joo et al.
safe. Further study of a larger number of patients with
longer follow-up is warranted.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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The clinical utility of the Kopitnik arteriovenous malformation microclip during STA-MCA bypass surgery 551


The clinical utility of the Kopitnik arteriovenous malformation microclip during STA-MCA bypass surgery

Crossref

A comparative study of intracranial aneurysm clips: closing and opening forces and physical endurance.

Comparative study of the pressure of various aneurysm clips.

Effects of surgical revascularization on outcome of patients with pediatric moyamoya disease.

End-to-side anastomoses in small arteries with partial lateral clipping. An experimental study.

Experience from “double-insurance bypass.” Surgical results and additional techniques to achieve complex aneurysm surgery in a safer manner. Surg Neurol 63:485–490 discussion 490

Intracranial vascular anastomosis using the microanastomotic system. Technical note.

Long-term assessment of cerebral perfusion following STA-MCA by-pass in patients. Stroke 16:85–91 The clinical utility of the Kopitnik arteriovenous malformation microclip during STA-MCA bypass surgery 551

Microsurgical cerebral revascularization for the treatment of stroke.

Microsuture-tying forceps with attached scissors for bypass surgery.

Microvascular hand surgery-transplants and replants-over the past 25 years.

The ELANA technique: constructing a high flow bypass using a non-occlusive anastomosis on the ICA and a conventional anastomosis on the SCA in the treatment of a fusiform giant basilar trunk aneurysm. Acta Neurochir (Wien)

The ELANA technique: high flow revascularization of the brain. Acta Neurochir Suppl (Wien)

The excimer laserassisted nonocclusive anastomosis practice model: development and application of a tool for practicing microvascular anastomosis techniques. Neurosurgery 58:ONS148–ONS156. doi:10.1227/01. NEU.0000193540.03756.BD discussion ONS148–156

Tulleken CA

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2829127

The clinical utility of the Kopitnik arteriovenous malformation microclip during STA-MCA bypass surgery

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